RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02237
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Special Forces Engineer, medically separated for “fracture/dislocation C2/C3, status post spinal fusion” with a disability rating of 20%.  

CI CONTENTION:  No specific contention was made.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20060509	VARD - 20061205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fracture/Dislocation C2/C3, Status Post Spinal Fusion	5241	20%	Status Post Open Reduction Internal Fixation with a Fusion of Second Cervical Third Cervical Subluxation with Possible Third Cervical Fracture	5237	20%	20060829	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Cervical Spinal Fusion.  According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered a neck injury during a deployment when he was ejected from a tactical vehicle in a rollover accident and landed on his head on 1 June 2005.  He was evacuated and initial X-rays revealed "50% anterior subluxation of C2 on to C3 and some irregularity of the C3 vertebral body suggesting possible fracture at that site."  He underwent a C2-C3 spinal fusion on 8 June 2005, and subsequently wore a hard collar and underwent physical and occupational therapy. Despite rehabilitative treatment, he could no longer meet special forces duty requirements and was given a permanent U3 profile in November 2005. 

During the 25 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the provider documented decreased cervical range of motion (ROM) with flexion to 15 degrees (normal 45) and a combined ROM of 125 degrees (normal 340).  The 11 April 2006 MEB NARSUM examination, 2 months before separation, noted CI complaints of constant, mild pain in the posterior aspect of the neck which was aggravated by from running or lifting more than 30 pounds.  He reported limitation in neck motion since surgery but had no radicular symptoms or paresthesias, and pain was improved with over-the-counter medications.  Physical examination showed a normal gait and no tenderness, spasm or deformity.  He had a well-healed posterior cervical scar with no redness or masses.  There were no motor or sensory deficits, and deep tendon reflexes were +2 and symmetrical in the upper extremities.  Measured ROM showed flexion of 30 degrees and a combined ROM of 165 degrees after repetition, with by complaints of mild pain and stiffness.  The provider also noted that “all limitations and restrictions were due to mechanical block.”  

At the 29 September 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant neck pain and stiffness, rated at 3/10, and increased to 7/10 when running or lifting/carrying objects more than 30 pounds.  He could accomplish activities of daily living with moderate restriction and did not lose time from work or experience incapacitating episodes.  Physical examination showed a normal gait and posture and mild fixed cervical spine deformities with tenderness along the back of the neck.  Flexion was to 30 degrees and combined ROM was 170 degrees, after repetition, and without pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical condition 20%, coded 5241 (spinal fusion), citing cervical spine ROM of 165 degrees and mechanical limits of spinal fusion.  The VA rated the cervical spine fusion condition 20%, coded 5237 (cervical strain), based on the C&P examination, citing mild fixed deformities and combined ROM of 170 degrees.  Members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) and/or combined ROM (not greater than 170 degrees) as reported on the MEB NARSUM and VA examinations.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the cervical spine fusion condition.  

BOARD FINDINGS:  In the matter of the cervical spine fusion condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010727, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure